Health Information Management
Encyclopedia
Health information management (HIM) is the practice of maintenance and care of health records
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....

 by traditional (paper-based) and electronic means in hospital
Hospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....

s, physician's
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...

 office clinics, health department
Health department
A health department or health ministry is a part of government which focuses on issues related to the general health of the citizenry. Subnational entities, such as states, counties and cities, often also operate a health department of their own...

s, health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...

 companies, and other facilities that provide health care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...

 or maintenance of health records. With the widespread computerization of health records and other information sources, including hospital administration functions
Hospital information system
There are various titles and acronyms which all declare similar approaches to managing the information flow and storage in hospital routine services, as*Hospital Information System , or*Healthcare Information System, or...

 and health human resources information
HRHIS
A “Human Resource for Health Information System” — also known within the health care sector as “human resource information system” — is a system for collecting, processing, managing and disseminating data and information on human resource for health...

, health informatics
Health informatics
.Health informatics is a discipline at the intersection of information science, computer science, and health care...

 and health information technology
Health information technology
Health information technology provides the umbrella framework to describe the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, government and quality entities, and insurers...

 are being increasingly utilized in information management
Information management
Information management is the collection and management of information from one or more sources and the distribution of that information to one or more audiences. This sometimes involves those who have a stake in, or a right to that information...

 practices in the health care sector
Health care system
A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations....

.

Health information management professionals plan information system
Information system
An information system - or application landscape - is any combination of information technology and people's activities that support operations, management, and decision making. In a very broad sense, the term information system is frequently used to refer to the interaction between people,...

s, develop health policy, and identify current and future information needs. In addition, they may apply the science of informatics
Informatics (academic field)
Informatics is the science of information, the practice of information processing, and the engineering of information systems. Informatics studies the structure, algorithms, behavior, and interactions of natural and artificial systems that store, process, access and communicate information...

 to the collection, storage, use, and transmission of information to meet the legal, professional, ethical and administrative records-keeping requirements of health care delivery. They work with clinical, epidemiological, demographic, financial, reference, and coded healthcare data.

It has been suggested the proper collection, management and use of information within healthcare systems “will determine the system’s effectiveness in detecting health problems, defining priorities, identifying innovative solutions and allocating resources to improve health outcomes.” For example, health information administrators have been described to "play a critical role in the delivery of healthcare in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...

 through their focus on the collection, maintenance and use of quality data to support the information-intensive and information-reliant healthcare system". As the field grows and information technology
Information technology
Information technology is the acquisition, processing, storage and dissemination of vocal, pictorial, textual and numerical information by a microelectronics-based combination of computing and telecommunications...

 becomes a more crucial part of the medical
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....

 world, health information management is experiencing a transition from traditional managing practices with paper to more efficient electronic management, such as with Electronic Health Records
Electronic Health Record
An electronic health record is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations...

 (EHRs). But the main goal is still to analyze, manage, and utilize the information that is essential to patient care and making sure the providers can access the information when necessary.

Background: Canada

Also called Health Record Technicians or Health Record Administrators.
Professional Association: Canadian College of Health Record Administrators (CCHRA)

Province of British Columbia

Educational Institution: Douglas College

HIM standards began with establishment of AHIMA

Health information management's standards history is dated back to the introduction of the American Health Information Management Association
American Health Information Management Association
-References:* -External links:* * * * * *...

, founded in 1928 "when the American College of Surgeons
American College of Surgeons
The American College of Surgeons is an educational association of surgeons created in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice.-Membership:...

 established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'"

In 1938, AHIMA was known as American Association of Medical Record Librarians (AAMRL) and its members were known as medical record experts or librarian
Librarian
A librarian is an information professional trained in library and information science, which is the organization and management of information services or materials for those with information needs...

s who studied medical record science. The goal of this career was to raise the standards of keeping records in hospitals and other healthcare facilities. The individuals involved in this profession were promoters for the successful management of clinical records to guarantee their precision.

Over time, the name AHIMA had changed to reflect the evolving field of health information management practices, eventually becoming the American Health Information Management Association. The association's current name is meant to cover the wide variety of areas health professionals work in today.

AHIMA members affect the quality of patient information and patient care at every touch point in the healthcare delivery cycle. They often serve in bridge roles, connecting clinical, operational, and administrative functions.

HIMSS establishment in 1961 increased industry knowledge

The Healthcare Information and Management Systems Society
Healthcare Information and Management Systems Society
The Healthcare Information and Management Systems Society is a not-for-profit organization dedicated to improving the quality, safety, cost-effectiveness, and access to healthcare through the best use of information technology and management systems. Originally founded in 1961 as the Hospital...

 (HIMMS) was organized in 1961 as the Hospital Management Systems Society (HMSS), an independent, unincorporated
Unincorporated entity
An unincorporated entity is an entity that has the same characteristics as a company but is not incorporated. It is also sometimes called a voluntary association....

, nonprofit
Non-profit organization
Nonprofit organization is neither a legal nor technical definition but generally refers to an organization that uses surplus revenues to achieve its goals, rather than distributing them as profit or dividends...

, voluntary association
Voluntary association
A voluntary association or union is a group of individuals who enter into an agreement as volunteers to form a body to accomplish a purpose.Strictly speaking, in many jurisdictions no formalities are necessary to start an association...

 of individuals. It was preceded by increasing amounts of management engineering
Management engineering (healthcare)
Management engineering or health systems engineering is a type of engineering in the field of healthcare.Health system engineering includes many different disciplines such as industrial engineering, operations research, management science and quality management.-External links:* * *...

 activity in healthcare during the 1950s, when teachings by Frederick Winslow Taylor
Frederick Winslow Taylor
Frederick Winslow Taylor was an American mechanical engineer who sought to improve industrial efficiency. He is regarded as the father of scientific management and was one of the first management consultants...

 and Frank Bunker Gilbreth, Sr. began to attract the attention of health leaders.

The HIMMS grew to include chapters, membership categories, publications, conventions, and continues to grow in different parts of the world via its Europe
Europe
Europe is, by convention, one of the world's seven continents. Comprising the westernmost peninsula of Eurasia, Europe is generally 'divided' from Asia to its east by the watershed divides of the Ural and Caucasus Mountains, the Ural River, the Caspian and Black Seas, and the waterways connecting...

, Asia Pacific, and Middle East
Middle East
The Middle East is a region that encompasses Western Asia and Northern Africa. It is often used as a synonym for Near East, in opposition to Far East...

ern branches.

Accredited educational program development

The Commission on Accreditation for Health Informatics and Information Management Education
Commission on Accreditation for Health Informatics and Information Management Education
The Commission on Accreditation for Health Informatics and Information Management Education is the accrediting organization for degree-granting programs in health informatics and health information management...

 (CAHIIM) defines standards which higher education
Higher education
Higher, post-secondary, tertiary, or third level education refers to the stage of learning that occurs at universities, academies, colleges, seminaries, and institutes of technology...

 health information management and technology programs must meet to qualify for accreditation
Accreditation
Accreditation is a process in which certification of competency, authority, or credibility is presented.Organizations that issue credentials or certify third parties against official standards are themselves formally accredited by accreditation bodies ; hence they are sometimes known as "accredited...

. Students who graduate from an accredited associate's
Associate's degree
An associate degree is an undergraduate academic degree awarded by community colleges, junior colleges, technical colleges, and bachelor's degree-granting colleges and universities upon completion of a course of study usually lasting two years...

, bachelor's
Bachelor's degree
A bachelor's degree is usually an academic degree awarded for an undergraduate course or major that generally lasts for three or four years, but can range anywhere from two to six years depending on the region of the world...

 or certificate
Academic certificate
An academic certificate is a document that certifies that a person has received specific education or has passed a test or series of tests.In many countries, certificate is a qualification attained in secondary education. For instance, students in the Republic of Ireland sit the Junior Certificate...

 program are qualified to sit for their respective exams for certification as a Registered Health Information Technician (RHIT) - via graduation from an accredited associate or certification program - or Registered Health Information Administrator (RHIA), which requires education through an accredited bachelor or certification program. Competency requirements are maintained by CAHIIM in their Associate Degree Entry-Level Competencies and Baccalaureate Degree Entry-Level Competencies definitions.

Electronic health records

The electronic health record has been continually expressed as an evolvement of health record-keeping. Because it is electronic, this means of record keeping has been both supported and debated in the health professional community and within the public realm.

In the United States, 89% of those who responded to a recent Wall Street Journal poll described themselves as "Very/Somewhat Confident" in their health care provider who used electronic health records compared to 71% of respondents who responded positively about their providers who didn't or don't use electronic health records. As of 2008, more than fifty-percent of Chief Information Officer
Chief information officer
Chief information officer , or information technology director, is a job title commonly given to the most senior executive in an enterprise responsible for the information technology and computer systems that support enterprise goals...

s polled listed that they wanted ambulatory electronic health records in order to have the health information record available to move across each stage of health care.

Health information managers are charged with the protection of patient privacy and are responsible for training their employees in the proper handling and usage of the confidential information entrusted to them. With the rise of technology's importance in healthcare, health information managers must remain competent with the use of information databases that generate crucial reports for administrators and physicians.

Educational programs

The requisites and accreditation processes for health information management education and professional activity vary across jurisdictions.

In the United States, the CAHIIM requires continued accreditation for accredited programs in health information management. The current standard is that accreditation may be maintained with periodic site visits, submission of an annual report, informing CAHIIM of adverse changes within the program and paying CAHIIM administrative fees. HIM students may opt to participate in a full-time bridge program
Bridge program (higher education)
A Bridge program is a higher education program specifically designed to assist a student with an attained initial educational level to attend college courses and achieve a terminal degree in the same field of study and in less time than an entry-level student would require...

 called the Joint Bachelor of Science/Masters Program. With this program, students can achieve both the Bachelor of Science in Health Information Management and the Master of Health Services Administration Program (BSHIM/MHSA). The full-time bridge program allows students to achieve both degrees in five years. Students pursuing the BSHIM/MHSA will be prepared to assume management and executive positions in health-related organizations such as: hospitals, managed care organizations, health information system developers and vendors, and pharmaceutical
Pharmacy
Pharmacy is the health profession that links the health sciences with the chemical sciences and it is charged with ensuring the safe and effective use of pharmaceutical drugs...

 companies, and bring their knowledge in HIM to these positions.

In Canada, graduates of Canadian Health Information Management Association (CHIMA) programs are eligible to write a national certification examination to pursue a profession in HIM.

Online program availability

There are many programs that are also available online. Online students collaborate with in-class students using internet technology. With online learning, students are allowed to go through the programs at their own pace. Online students are included in class through group lectures that are recorded and put online, discussion boards and are members of group projects with in-class students. Some online students are even allowed to attend some classes on campus and take some classes online.

The CAHIIM lists accredited online programs on its website.

Further education for health information professionals

Education is an important aspect in being successful in the world of health information management. Aside from initial credentials, health information professionals may wish to pursue a Masters of Business Administration, Masters of Health Administration, or other Masters programs in health data management, information technology and systems, and organization and management. Gaining further education advances the health professional's career and qualifies the individual for upper-management positions.

Records and practices used in health information management

Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future. Continuous quality management of data standards and content is key to ensuring that information is usable and actionable.

Records

  • The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases. This repository of information about a single patient is generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient.

  • The primary patient record is the record that is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions.

  • The secondary patient record is a record that is derived from the primary record and contains selected data elements to aid non clinical persons in supporting, evaluating and advancing patient care. Patient care support refers to administration, regulation, and payment functions.

Methods to ensure Data Quality

The accuracy of data depends on the manual or computer information system design for collecting, recording, storing, processing, accessing and displaying data as well as the ability and follow- through of the people involved in each phase of these activities. Everyone involved with documenting or using health information is responsible for its quality. According to AHIMA’s Data Quality Management Model, there are four key processes for data:
  1. Application: the purpose for which the data are collected.
  2. Collection: the processes by which data elements are accumulated.
  3. Warehousing: the processes and systems used to store and maintain data and data journals.
  4. Analysis: the process of translating data into information utilized for an application.


Each aspect is analyzed with 10 different data characteristics:
  1. Accuracy: Data are the correct values and are valid.
  2. Accessibility: Data items should be easily obtainable and legal to collect.
  3. Comprehensiveness: All required data items are included. Ensure that the entire scope of the data is collected and document intentional limitations.
  4. Consistency: The value of the data should be reliable and the same across applications.
  5. Currency: The data should be up to date. A datum value is up to date if it is current for a specific point in time. It is outdate if it was current at some preceding time yet incorrect at a later time.
  6. Definition: Clear definitions should be provided so that current and future data users will know what the data mean. Each data element should have clear meaning and acceptable values.
  7. Granularity: The attributes and values of data should be defined at the correct level of detail.
  8. Precision: Data values should be just large enough to support the application or process.
  9. Relevancy: The data are meaningful to the performance of the process or application for which they are collected.
  10. Timeliness: Timeliness is determined by how the data are being used and their context.

Health information professionals

HIM is a very broad and successful field for health care professionals
Health care provider
A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....

. There are several career opportunities in Health Information Management and many different traditional and non-traditional settings for an HIM professional to work within.
  • Traditional settings include: Managing an HIM medical records department, cancer registry
    Cancer registry
    A cancer registry is a systematic collection of data about cancer and tumor diseases. The data is collected by Cancer Registrars. Cancer Registrars capture a complete summary of patient history, diagnosis, treatment, and status for every cancer patient in the United States, and other countries as...

    , coding
    Medical classification
    Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers...

    , trauma registry, transcription
    Medical transcription
    Medical transcription, also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals, into text format.-History:...

    , quality improvement
    Quality management
    The term Quality management has a specific meaning within many business sectors. This specific definition, which does not aim to assure 'good quality' by the more general definition , can be considered to have four main components: quality planning, quality control, quality assurance and quality...

    , release of information
    Release of Information department
    A release of information department or division is found in virtually every hospital. In the United States, HIPAA and State guidelines strongly direct the rules and regulations of patient information...

    , patient admissions, compliance auditor, physician accreditation, utilization review, physician offices and risk management
    Risk management
    Risk management is the identification, assessment, and prioritization of risks followed by coordinated and economical application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events or to maximize the realization of opportunities...

    .
  • Non-traditional settings include: consulting firms, government agencies, law firms, insurance companies, correctional facilities, extended care facilities, pharmaceutical research, information technology and medical software
    Medical software
    In computers, medical software is a significant branch of software engineering. Many medical devices that monitor or control patients are predominantly controlled by software. Medical devices are frequently regulated and must comply with local and regional laws. In the European Union, these...

     companies.

Health information managers

Professional health information managers manage and construct health information programs to guarantee they accommodate medical, legal, and ethical standards. They play a crucial role in the maintenance, collection, and analyzing of data that is received by doctors, nurses, and other healthcare players. In return these healthcare data contributors rely on the information to deliver quality healthcare. Managers must work with a group of information technicians to guarantee that the patient's medical records are accurate and are available when needed.

In the United States, health information managers are typically certified as a Registered Health Information Administrator (RHIA) after achieving a bachelor's degree in health informatics or health information management from a school accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and after passing their respective certification exam. The Certified Health Informatics Systems Professional (CHISP) certification offered by American Society of Health Informatics Managers (ASHIM) is to credit a working level IT or clinical professional who is able to support physician adoption of Health IT. A CHISP professional needs to process knowledge of the health care environment, Health IT, IT, and soft skills including communication skills.

RHIAs usually assume a managerial position that interacts will all levels of an organization that use patient data in decision making and everyday operations. They may work in a broad range of settings that span the continuum of healthcare including office based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies.

Health information managers may specialize in registry management, data management, and data quality among other areas.

Medical records and health information technicians

Medical records and health information technicians (MRHIT) are described as having the following duties according to the U.S. Bureau of Labor Statistics' Occupational Outlook Handbook:
assemble patients' health information including medical history, symptoms, examination results, diagnostic tests, treatment methods, and all other healthcare provider services. Technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security. They regularly communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain additional information.


The International Labour Organization's International Standard Classification of Occupations
International Standard Classification of Occupations
The International Standard Classification of Occupations is an International Labour Organization classification structure for organizing information on labour and jobs. It is part of the international family of economic and social classifications of the United Nations...

 further notes: "Occupations included in this category require knowledge of medical terminology, legal aspects of health information, health data standards, and computer- or paper-based data management as obtained through formal education and/or prolonged on-the-job training.

MRHITs usually work in hospitals. However they also work in a variety of other healthcare settings, including office based physician practices, nursing home
Nursing home
A nursing home, convalescent home, skilled nursing unit , care home, rest home, or old people's home provides a type of care of residents: it is a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living...

s, home health agencies
Home care
Home Care, , is health care or supportive care provided in the patient's home by healthcare professionals Home Care, (also referred to as domiciliary care or social care), is health care or supportive care provided in the patient's home by healthcare professionals Home Care, (also referred to as...

, mental health facilities
Psychiatric hospital
Psychiatric hospitals, also known as mental hospitals, are hospitals specializing in the treatment of serious mental disorders. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients...

, and public health agencies. Technicians who specialize in coding are called medical coders or coding specialists.

In the United States, Registered Health Information Technologists must pass an accredited Health Information Technology program before they may take their certification exam.

Professional organizations



See also

  • Human resources for health (HRH) information systems
    HRHIS
    A “Human Resource for Health Information System” — also known within the health care sector as “human resource information system” — is a system for collecting, processing, managing and disseminating data and information on human resource for health...

  • Hospital information system
    Hospital information system
    There are various titles and acronyms which all declare similar approaches to managing the information flow and storage in hospital routine services, as*Hospital Information System , or*Healthcare Information System, or...

    s
  • Medical classification
    Medical classification
    Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers...

    s

External links

The source of this article is wikipedia, the free encyclopedia.  The text of this article is licensed under the GFDL.
 
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